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Accessibility to meds often restricted for exchange plans, study suggests

Prescription drug coverage is one of the 10 essential health insurance benefits that the Affordable Care Act requires qualified plans to have. But according to a new analysis, the availability of medicines through the exchange-offered plans is often lacking.

Consumers who get health insurance through the federal- or state-based marketplaces are approximately two times more likely to face “utilization management controls,” according to advisory services firm Avalere Health. Controls may include step therapy or prior authorization.

For example, among prescriptions used to treat tumors, roughly 70 percent of oncology medications had utilization controls in place, Avalere’s study revealed.

“This is one more reminder that consumers shopping on the exchange need to look beyond premium costs when picking a plan,” said Caroline Pearson, vice president at Avalere. “Patients may be better off selecting a plan that includes open access for drugs they use regularly.”

She added that in those instances where prior authorization is required, consumers will have to work closely with their doctors to avoid unnecessary hurdles.

Increasing consumer access is one of the reasons why supporters of the ACA have a favorable opinion of it, according to a recent poll from Kaiser Family Foundation.

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Erin Woulfe
Erin Woulfe
Erin Woulfe likes to write about things that matter. Keeping her finger on the pulse of what’s happening in the public sector world, she blogs about the latest legislative news and employee benefit trends that affect our school, city and county clients. She’s been with NIS since 2002. “I love connecting to our clients and providing them with the tools they need in order to administrate their plan,” says Erin. “Whether that be materials to educate their employees on certain benefits, how to effectively communicate change within an organization or just providing tips and how-to’s to help them make their job easier.”

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